Comprehensive Gaps Analysis of Behavioral Health …leg.state.nv.us/interim/77th2013/Committee/StatCom/HealthCare/...• The current behavioral health service delivery system at the

Comprehensive Gaps Analysis of

Behavioral Health Services

Nevada Department of

Health and Human Services DIVISION OF PUBLIC AND BEHAVIORAL HEALTH

Presented by:

Kelly Marschall, MSW

February 5, 2014

Legislative Committee on Health Care

Purpose of the Report

The purpose of the gaps analysis

report was to forward the efforts of

the state to implement a system of

care as Nevada integrates Public

and Behavioral Health by

identifying gaps in the service

delivery system.

Content of the Report

The gaps analysis report includes a

mapping and analysis of behavioral

health services in Nevada using the

SAMHSA strategic prevention

framework. (March – September

2013)

The report summarizes:

• The current behavioral health service delivery

system at the state and local level at a point in

time,

• Unmet needs related to behavioral health, and

• Opportunities and recommendations for systems

improvement.

Method of the Report

Conducting a gaps analysis is simplified within a

defined system of stable service delivery components

where consistent and reliable longitudinal data are

available for analysis. The system at the point in time

of the analysis is compared to the defined system as

intended.

The variance between the two systems and the

outcomes sought versus achieved are used to identify

gaps.

Unfortunately, these circumstances did not exist

during the development of this report.



A combination of qualitative and quantitative data was

used to complete the gaps analysis.

• Qualitative data such as key informant interviews,

group meeting participation, and consumer

surveys were used to gather input from a variety of

stakeholders to discern the resources in use and

the gaps related to behavioral health in their area

of concern.

• Quantitative data such as estimated need, service

provider capacity, and utilization rates were

collected and analyzed. Research from US

sources was utilized to calculate unmet needs.

Context of the Report

This study took place during a significant time of

transition and turmoil within the State of Nevada

related to behavioral health.

• The state was preparing for integration efforts

across multiple state departments.

• Biennial legislature was in session, tasked with

budget passage.

• The state became the target of public scrutiny as a

result of a number of issues related to the care and

treatment of behavioral health clients.

Context of the Report:

Integration Efforts

Integration of Mental Health and Developmental

Services (MHDS) and the Health Division into the

Division of Public and Behavioral Health (DPBH)

became official on July 1, 2013.

The integration efforts are a work in progress:

• Uniform policies and procedures do not exist

system wide.

• Staffing resources and service provision continue

to function in silos.

• Data to quantify services provided and identify

ongoing need are not reliably captured.


Legislative Session

• Integration required passage of the 2013-2015

budget by a legislature that was in session from

February to June 2013. Excessively long wait

times for clients at the state operated forensic

facility

• The required presence of Division leadership

during the legislative session further impacted the

ability to move forward with implementation.

• Regulations that require separate budgets for

SNAMHS, NNAMHS and RCSS created inflexibility

to meet the changing needs of the system as a

whole.


Public Scrutiny

From March through August 2013, the State of

Nevada faced a number of difficult circumstances

surrounding the operations of publicly supported

behavioral health services throughout the state.

• Allegations of improper discharge practices

• Excessively long wait times for clients at the state

operated forensic facility

• Infractions within state psychiatric facilities that

could jeopardize their Center for Medicare &

Medicaid Services (CMS) certification

Limitations of the Report:

Several limitations are important to consider regarding the

content of the report:

• Systems are constantly in flux and this report describes

a point in time that doesn’t include changes or events

that occurred after September 2013

• Comparison data for penetration rates and financing

include state data reported in multiple manners by

states

• Federal expenditure reports only include Medicaid funds

to the extent that they flow through the state mental

health authority; states may bypass the SMHA with

some Medicaid funds for mental health services

• While census data was used for projections and

included undocumented individuals, little is known about

the needs of that subpopulation

Description of Current Service System

The behavioral health system in Nevada is comprised

of federal, state and local resources that operate

under a variety of funding sources, priorities and

mandates.

Services throughout the state differ based on target

population, geographic region and funding source.

As a result, there are often different challenges for

persons seeking behavioral health assistance based

on services available and where they are sought.

Description of Current Service System:

Primary Provider

The most significant provider of public behavioral

health services in Nevada is the Division of Public

and Behavioral Health (DPBH).

There are 4 service delivery systems that operate

within DPBH to provide behavioral health care:

• Northern Nevada Adult Mental Health Services

• Southern Nevada Adult Mental Health Services

• Rural Counseling and Supportive Services; and

• Lake’s Crossing.


Financing Behavioral Health

PER CAPITA

BEHAVIORAL HEALTH

EXPENDITURES

FFY04 FFY05 FFY06 FFY07 FFY08 FFY09 FFY10

Nevada

$ per capita $54 $63 $61 $79 $81 $64 $68

Rank 40 39 42 33 36 41 43

United

States $ per capita $93 $100 $104 $113 $121 $123 $121

The table below demonstrates that Nevada’s per

capita behavioral health spending has and

continues to be significantly lower than the

national average (Foundation, 2013).*

*updated numbers to be provided by DHHS


Financing Behavioral Health


Financing Services

The following map illustrates how Nevada

compares to the rest of the nation in per-person

behavioral health spending for FY2010

(Foundation, 2013).


Missed Opportunities

Nevada has missed a number

of opportunities over the years

to strengthen its behavioral

health system in response to

previous reforms.

These opportunities go back to

the adoption of the Community

Mental Health Act of 1963

(CMHA), some 50 years ago.

“Officials have known

about solutions for

decades, economic

recessions and budgetary

constraints have kept

them from fully and

consistently

implementing mental

health programming.”

The Las Vegas Sun,

August 2013


50 Year Retrospective

Profile of Current Behavioral

Health Consumers

The Report examined the profile of behavioral health

consumers based on:

• Age,

• Gender and,

• Race.

Additionally, penetration rates were explored to

identify how well the state of Nevada was reaching

consumers in need of behavioral health services.


Health Consumers: Age

In Nevada, the largest category of consumers accessing

care is between the ages of 25-44, representing 38% of the

service population. This is followed by consumers between

the ages of 45-65, representing 35% of the service

population.


Health Consumers: Age

Penetration Rates indicate that Nevada serves one

child (ages 0-12) for every four, on average, served

nationally and one senior (ages 75+) to every 12

served nationally.


Health Consumers: Gender

Female consumers make up the largest demographic of

individuals accessing care, representing 53% of the service

population. Male consumers represent the remaining 47%

of the service population.


Health Consumers: Gender

Nationally averaged penetration rates for females account

for 23.1 persons per 1,000 people in the population,

compared to 11.3 persons in Nevada. Nationally averaged

penetration rates of services to men, (22.1 per 1,000) also

exceed Nevada’s rate of 9.9 per 1,000.


Health Consumers: Race

Behavioral health consumers served largely reflect the

racial demographics of the state.


Health Consumers: Ethnicity

While 26.5% of the population in Nevada is

Hispanic/Latino, they only represent 12.5% of those

served.

Additionally, penetration rates reveal that Nevada reaches

a significantly lower percentage of Hispanic consumers

needing services when compared to national averages.

Unmet Need

A multi-step formula was used to establish an estimate of

unmet need related to behavioral health services.

Step 1: To identify the population in Nevada that need behavioral

health support and are eligible to receive it through public

provisions, the following formula was used:

( 2010

CENSUS

DATA X

% OF POPULATION

ELIGIBLE FOR

MEDICAID IN

NEVADA ) X

ESTIMATED % OF

PEOPLE CONSIDERED

SED/AMI/SMI =

PEOPLE IN NEVADA NEEDING

AND ELIGIBLE FOR PUBLIC

MENTAL HEALTH SERVICES

Step 2: To identify the unmet need of people in Nevada that

required behavioral health services and were eligible to receive

them through public provision, yet did not, the following formula

was used:

PEOPLE IN NEVADA

NEEDING AND ELIGIBLE

FOR PUBLIC

BEHAVIORAL HEALTH

SERVICES

- NUMBER OF PEOPLE WHO

ACCESSED PUBLIC BEHAVIORAL

HEALTH SERVICES =

PEOPLE IN NEVADA NEEDING AND ELIGIBLE

FOR PUBLIC BEHAVIORAL HEALTH SERVICES

BUT NOT RECEIVING THEM (UNMET NEED)

Unmet Need: Children

In Fiscal Year (FY) 2011-

2012, there were a total of

12,399 children in the state

that were Medicaid eligible

and estimated to have a

serious emotional

disturbance (SED).

Of that total, the state

provided services to 3,989

in FY 2011-12,

representing 32% of the

estimated need.

Unmet Need: Children

DCFS’s service population totaled

10,991, of which 2,927 were

served, representing approximately

27% of the estimated need.

DPBH’s service population totaled

1,408, of which 931 were served,

representing approximately 66%

of the estimated need. A total of

477 (34%) children were

estimated to be in need of but not

receiving services in FY 2011-12.

Unmet Need: Adults

There are a total of 88,956

adults in the state of

Nevada that are Medicaid

eligible and are considered

to have any mental illness

(AMI) or a severe mental

illness (SMI).

Of that total, DPBH

provided services to

25,522 in FY 2011-12,

representing 29% of the

total of those estimated to

be in need.

Unmet Need:

Consumer Survey

A Consumer Survey was issued to identify how

people access services, their satisfaction with

services received and identification of gaps in the

service delivery system.

Surveys were distributed throughout the state to

social service providers that did not provide

behavioral health services.

Providers included food pantries, family resource

centers and health and human service organizations.

A total of 339 individuals completed the survey.

Unmet Need:

Consumer Survey

62% of those who responded indicated that behavioral

health concerns were a big issue in their community with a

lot of needs that remain unaddressed.

Unmet Need:

Consumer Survey

Respondents varied in how well they rated the current

system in responding to the behavioral health care needs

of the community.

Unmet Need:

Consumer Survey

Respondents were given a list and asked to indicate

whether the issue was a concern or barrier for them.

Unmet Need

Data Indicates:

• Services are currently reaching people in their middle

stages of life, with insufficient resources for prevention

or early intervention.

• Services are not sufficient to meet the needs of people

later in life.

• A culturally competent framework to provide services to

Nevada’s growing minority population is needed.

• Insufficient service reach is most pronounced in the

southern region of the state, as indicated by statistics

that reveal only 24% of people eligible and needing

assistance are being served.

Gaps in Services

While statistics were combined with existing

publications to identify what gaps exist in the

public behavioral health system, information

gathered through key informant interviews and

consumer surveys was used to explain why gaps

in services exist.

Gaps in Services

Key informants identified a number of

weaknesses that need to be addressed to

strengthen the system.

• Workforce

• Provider Network

• Resources

• Competing Priorities

Gaps in Services

The following threats were identified that

pose challenges to the system if not

adequately addressed:

• Credibility

• Loss of Funding

• Staffing Shortages

• Housing

• Substance Abuse Services

Gaps in Services

The following gaps were also noted:

• Lack of bilingual staff and specialty

providers

• Uneven access to types and quality of

services depending on location in the state

• Lack of resources for children, teens and

seniors

• Transportation challenges

• Difficulty in obtaining services when in

crisis

Gaps in Services

Statements from Key Informant Interviews signify the

issues facing the Behavioral Health System:

• The “private mental health provider community hasn’t

evolved like other states” because of the state operated

system.

• Even the most sophisticated service providers describe

the, “impossibility of getting an involuntary commitment

in northern Nevada.”

• “There is a lack of supportive housing for those who

can’t live independently but don’t need to be locked up.”

• “For those in mental health court, for a year, they

receive intensive support. Once they are discharged,

that support often ends.”

• “I worry that instead of fully integrating substance abuse

and mental health that the good parts of mental health

will feel the impact.”

Gaps in Services

Intervention once law enforcement is involved is the norm

Recommendations

Nevada has an opportunity to implement a behavioral

health system that is community-based,

comprehensive and efficient. The gaps analysis is

intended to assist the state in understanding gaps

and taking steps to address them. To do so, three

focus areas are recommended.

• Ensure accountability, credibility and high quality

services.

• Develop community and state capacity to

implement no wrong door

• Establish a vision and plan for the system of care

and secure the resources necessary to implement

the plan

Recommendations

When designing a system of care, a number of

specific components are needed and detailed below:

• Prevention/Education

• Identification, Outreach and Access

• Assessment and Evaluation

• Behavioral Health Treatment

• Housing

• Coordination with Health Care

• Care Management

• Crisis Response Service

• Protection and Advocacy

• Peer Support

• Social Rehabilitation

“There is a consequence for our whole community

when people need services and can’t get them.

We have an opportunity to intervene early in the

process and provide services or we can leave it

unaddressed and that portion of the populations

is less happy, less productive and possibly

dangerous. We do no kindness by letting folks

suffer with their mental illness.”

Key Informant Comment

Questions/Comments?

Documents

Comprehensive Gaps Analysis of Behavioral Health …leg.state.nv.us/interim/77th2013/Committee/StatCom/HealthCare/...• The current behavioral health service delivery system at the